Community Care Licensing

Document Has Been Signed on 12/31/2024 03:15 PM - It Cannot Be Edited

Sheila Santos TELEPHONE: (714) 334-2062 Joseph Alejandre TELEPHONE: 714-705-6018 DATE: 12/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024

FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #1	FACILITY NUMBER: 306003654
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2024

Section Cited

All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited abovewhich poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have a new Administrator with a valid administrator's certificate named as the facility's new Administrator. LIcensee to submit a copy of the required documents to update the facility's administrator.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Sheila Santos TELEPHONE: (714) 334-2062 Joseph Alejandre TELEPHONE: 714-705-6018 DATE: 12/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024

FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #1	FACILITY NUMBER: 306003654
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2024

Section Cited

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out 5 residents, Resident 1 had no Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have a Physician's report completed for Resident 1 by the POC due date. Licensee to forward proof to LPA by the POC due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Sheila Santos TELEPHONE: (714) 334-2062 Joseph Alejandre TELEPHONE: 714-705-6018 DATE: 12/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024

FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #1	FACILITY NUMBER: 306003654
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2024

Section Cited

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 3 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Licensee agrees to complete resident appraisals for Resident 1, Resident 2 and Resident 4 by the POC due date. Licensee to forward proof to LPA by the POC due date.

Sheila Santos TELEPHONE: (714) 334-2062 Joseph Alejandre TELEPHONE: 714-705-6018 DATE: 12/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024

FACILITY NAME: TESSIE'S PLACE LOVING CARE HOME #1	FACILITY NUMBER: 306003654
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2024

Section Cited

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above, there is no documentation for a recent drill being conducted which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2025
	Plan of Correction
1 2 3 4	Licensee agrees to conduct an emergency drill and to document the training. Licensee to submit proof of training to LPA by POC due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Sheila Santos TELEPHONE: (714) 334-2062 Joseph Alejandre TELEPHONE: 714-705-6018 DATE: 12/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024